Background Gastroesophageal reflux disease (GERD), functional dyspepsia (FD), and irritable bowel syndrome (IBS) are common gastrointestinal diseases. Several studies have shown a significant occurrence of overlap among these 3 diseases. The purpose of this study was to examine the factors associated with such disease overlap in Japanese adults.
Methods We performed a cross-sectional study on Japanese workers who visited a clinic for a routine health check-up and asked them to fill out a self-report questionnaire. GERD was defined as episodes of heartburn and/or acid regurgitation at least once a week, and the diagnosis of FD and IBS was based on Rome III criteria. A logistic regression model was used to identify risk factors, and odds ratio (OR) was calculated with 95% confidence intervals (CIs).
Results Disease overlaps were found in 160 (6.0%) of the 2680 eligible subjects. Female gender was associated with GERD + IBS (OR=1.99; 95% CI, 1.06-3.75), and FD + IBS (OR=1.72; 95% CI, 1.03-2.85), and lower body mass index was negatively associated with FD + IBS (OR=0.54; 96% CI, 0.34-0.87). Cigarette smoking was a common factor associated with the overlaps: GERD + FD (OR=2.14; 95% CI, 1.22-3.76), GERD + IBS (OR=3.16; 95% CI, 1.75-3.71), FD + IBS (OR=2.26; 95% CI, 1.40-3.66), and GERD + FD + IBS (OR=4.08; 95% CI, 1.66-10.07). The associations between smoking habits and overlaps were stronger in smokers who smoked ≥1 pack per day as compared to those who smoked <1 pack per day.
Conclusion Cigarette smoking was significantly associated with overlaps among GERD, FD, and IBS in Japanese adults.

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Objective The aim of this study was to assess the changes in the clinical parameters during intragastric balloon therapy for Japanese obese patients.
Methods Between March 2009 and September 2010, 8 patients underwent intragastric balloon therapy at our hospital. The visceral fat area, liver volume and the liver-spleen ratio were measured by computed tomography. Blood examination and computerized tomography were performed before the balloon placement, and at 1, 3 and 6 months after the balloon placement in all of the patients.
Results Eight patients (5 males and 3 females, median age, 39 years; median BMI, 44.0 kg/m²) underwent intragastric balloon therapy without severe complications. The median weight loss was 8.6 kg, mean BMI loss was 2.8 kg/m², and the percent excess weight loss was 14.8% at 6 months after the balloon placement. The body weight and liver volume decreased significantly during the first month, and the results were maintained at the same levels until after the second month. The liver-spleen ratio also improved significantly during the first month, but worsened again during the last 3 months. The visceral fat area showed no significant differences during the treatment as well as no differences in liver enzymes, glucose and lipid metabolism.
Conclusion Intragastric balloon therapy achieved a moderate effect in weight and liver volume reduction during the early months of the treatment. Intragastric balloon therapy may have a role as a minimally invasive method for pretreatment before laparoscopic surgery.

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Objective A number of chemokines and chemokine receptors are produced by intrinsic renal cells as well as by infiltrating cells during renal inflammation. The CCR2 chemokine receptor mediates leukocyte chemoattraction in the initiation and amplification phase of renal inflammation. The polymorphism, CCR2-V64I, changes valine 64 of CCR2 to isoleucine. We aimed to determine the frequency of CCR2-V64I polymorphism in patients with chronic renal failure requiring long-term hemodialysis.
Methods and Patients The PCR-based restriction fragment length polymorphism (PCR-RFLP) technique was used to assess the gene frequencies of CCR2-641 in CRF patients (n=210) and healthy controls (n=139) in the current study.
Results The frequencies of the CCR2 genotype were 0.68 for V/V, 0.28 for V/I, and 0.4 for I/I in the CRF patients and 0.81 for V/V, 018 for V/I and 0.1 for I/I in healthy controls. The distribution of the CCR2-V64I mutant genotype was significantly different between subjects with CRF and healthy control subjects (X2=7.197 and p=0.027).
Conclusion We found that the CCR2-V64I polymorphism was significantly high in CRF patients. In addition to the contribution to disease pathogenesis, it was recently found that chemokines have therapeutic importance in chronic renal failure. The frequency of CCR2-V64I and other chemokine and chemokine receptor polymorphisms in renal pathologies must be further investigated in larger study populations and in different renal diseases.

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Objective To evaluate the mid-term outcomes of sirolimus-eluting stents (SES; Cypher Bx Velocity) for de novo coronary stenosis in a Japanese clinical setting, and to compare these with the outcomes using bare-metal stents (BMS).
Methods This study was a nonrandomized, lesion-based, and single-center study, retrospectively investigated in October 2010. We enrolled 2031 consecutive cases with de novo coronary lesions treated with BMS (n=587) or SES (n=1,444) from January 2003 to May 2007. SES use ratio during the available interval was 95.5%. The primary endpoint was the incidence of target vessel failure (TVF: comprising cardiac death, nonfatal recurrent MI, definite stent thrombosis (ST), and severe restenosis [% diameter stenosis (%DS) at secondary angiography ≥70%]. The secondary endpoint was the incidence of binary in-stent restenosis (%DS >50%).
Results The TVF ratio after SES placement (6.6%) was significantly lower than that after BMS placement (11.8%, p<0.001), despite many disadvantageous variables in the SES group. SES related to the risk of TVF (mean follow-up for SES, 1,411 ± 539 days; BMS, 1,818 ± 825 days) (hazard ratio of 0.428 at 95% CI, 0.292-0.627, p<0.001). The ratio of binary in-stent restenosis after SES placement (13.4%) was significantly lower than that after BMS placement (25.1%; p<0.001). SES was significantly related to binary in-stent restenosis (odds ratio of 0.267 at 95% CI, 0.195-0.366, p<0.001).
Conclusion SES has a more favorable mid-term clinical and angiographic outcome than BMS for de novo coronary stenosis in clinical settings in Japan.

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Background Hyperglycemia on admission is a predictor of an unfavorable prognosis in patients with ST-elevation Acute Myocardial Infarction (AMI). Data concerning associations between an elevated glucose level on admission and other in-hospital complications are still limited.
Methods A total of 1,137 AMI patients with complete admission blood glucose level (ABGL) analysis were identified and stratified according to ABGL.
Results A total of 16.1% patients had admission glucose level <5 mmol/L, 36.1% <7 mmol/L, 20.2% <9 mmol/L, 9.9% <11 mmol/L and 17.7% ≥11 mmol/L. Compared with the euglycemia group, both the hypo- and hyperglycemia groups were associated with higher in-hospital mortality. In-hospital mortality of diabetic patients with hypoglycemia (12.2%) was higher than that of diabetic patients with either euglycemia or mild hyperglycemia (11.1%, or 10.7% relatively). The same results were seen in non-diabetic patients. In the logistic regression analysis, admission glucose and cardiac function of Killip grade were the independent predictors of in-hospital death for patients with AMI.
Conclusion Elevated admission glucose levels are associated with an increased risk of life-threatening complications in diabetic and non-diabetic AMI patients. Compared with the euglycemia group, hypoglycemia was associated with a higher trend of in-hospital mortality.

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Objective We analyzed the efficacy and safety of Preminent^® [losartan(50 mg/day)/HCTZ(12.5 mg/day)] compared to CodioMD^® [valsartan(80 mg/day)/HCTZ(6.25 mg/day)].
Methods In this study, 31 hypertensive patients after receiving 3 months of Preminent^® (Stage A) were enrolled. We applied a changeover with switching from Preminent^® to CodioMD^® (Stage B). We then applied another changeover with switching from CodioMD^® to Preminent^® after 3 months (Stage C).
Results Average values of 24-h blood pressure (BP), daytime BP and nighttime BP using ambulatory BP monitoring (ABPM) significantly increased from Stage A to B [4/3 mmHg, 5/3 mmHg and 3/3 mmHg, respectively]. Average values of 24-h BP, morning BP, daytime BP, nighttime BP significantly decreased from the end of Stage B to C [-5/-5 mmHg, -4/-6 mmHg, -5/-5 mmHg and -6/-4 mmHg, respectively]. Interestingly, the serum levels of uric acid and the urinary albumin/creatinine ratio showed a significant increase after the change to CodioMD^®. Since these adverse effects did not disappear after the return to Preminent^® at the end of Stage C, we performed an additional 3-month follow-up (extended stage). These adverse effects finally disappeared at the end of this extended stage.
Conclusion Single-pill fixed-dose combination therapy using Preminent^® showed significant 24-h BP-lowering effects and was safe when compared with CodioMD^®.

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Objective The aim of this study was to determine whether elevated depressive symptoms are associated with metabolic syndrome and its components in the Japanese population.
Methods Out of 1,386 male workers who underwent measurements of variables of metabolic syndrome components in their health checkup, 1,186 subjects (44.5 ± 9.6 years) completed the Zung self-rating depression scale (ZSDS) (response rate 85.6%). In this study, metabolic syndrome was defined according to the joint scientific statement proposed by 6 major organizations, including the International Diabetes Federation.
Results The overall frequency of elevated depressive symptoms (ZSDS scores ≥40) was 42.1% (n=499). The incidence of metabolic syndrome was significantly higher in subjects with elevated depressive symptoms than in those without (13.2% vs. 8.9%, p<0.05). Of all the metabolic syndrome components, mean triglyceride levels were significantly higher in subjects with elevated depressive symptoms than in those without [124.7 (95% confidence interval (CI): 117.8-131.7) mg/dL vs. 111.5 (95% CI: 107.2-115.9) mg/dL, p<0.05]. Consequently, hypertriglyceridemia (28.9% vs. 21.0%, p<0.01) was the main component correlated with the between-group difference of metabolic syndrome incidence. In the logistic regression analysis after adjustment for potential confounders, the odds ratio of the total ZSDS scores for the diagnosis of hypertriglyceridemia was 1.52 (95% CI: 1.13-2.04; p<0.01), and the major depressive symptom was psychomotor agitation (odds ratio: 1.47; 95% CI: 1.10-1.94; p<0.01).
Conclusion This study showed that elevated depressive symptoms were associated with hypertriglyceridemia in Japanese male workers, which affected the clinical diagnosis of metabolic syndrome.

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Objective Many studies have revealed that white blood cell count (WBC) is related to insulin resistance which is a central mechanism of metabolic syndrome (MetS). However, few cohort studies have examined the role of WBC in the development of MetS. We hypothesized that WBC is associated with the future development of MetS, and investigated the longitudinal incidence of MetS in healthy workers.
Methods WBC was measured in 5,073 workers (mean age 42.5 years) without MetS at baseline. The incidence of MetS was monitored over 7 years of follow-up, in relation to quartiles of WBC. During the follow-up, 925 participants were diagnosed as MetS.
Results Incidence of MetS was increased in participants with higher WBC: the rates of incidence of MetS were 22.6, 32.9, 42.9, and 57.5 per 1,000 person-years of follow-up in the 1st, 2nd, 3rd, and 4th quartiles of WBC, respectively. After adjustments for confounding factors, the adjusted hazards ratio (95% confidence interval) for MetS was 1.00 (reference), 1.22 (0.98 to 1.51), 1.52 (1.24 to 1.87), and 1.66 (1.35 to 2.04) through the quartiles of WBC, respectively, (p <0.001). This relationship was consistent among current smokers and never smokers, and among male and female genders, respectively.
Conclusion WBC is useful in predicting the future development of MetS which leads to atherosclerotic diseases.

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Objective Sleep is one of the major means to maintain health. The association of short sleep duration with obesity, diabetes, fatty liver and behavioral factors requires further exploration.
Methods A total of 8157 Japanese men who underwent health evaluations were divided into 3 groups by sleep duration <5 hours, 5~<7 hours and ≥7 hours. Poor sleep was self-reported, being defined as difficulty of getting to sleep or awakening easily. The age-adjusted and age and poor sleep-adjusted odds ratios of the 3 groups for obesity, diabetes, fatty liver, mental stress, poor sleep, regular exercise and late dinner time were investigated.
Results Compared to the sleep duration 5~<7 hours group, the age-adjusted odds ratios of the <5 hours group were significantly higher for obesity (1.42), diabetes (1.63), mental stress (1.75), poor sleep (1.85), late dinner time (1.47), and significantly lower for regular exercise (0.61); while those of the ≥7 hours group were significantly lower for obesity (0.73), fatty liver (0.82), mental stress (0.73), poor sleep (0.69), late dinner time (0.45), and significantly higher for regular exercise (1.27). Above significances still existed after adjustment for age and poor sleep.
Conclusion Short sleep duration is associated with obesity, diabetes, fatty liver and multiple behavioral factors. The optimal sleep duration for health promotion and effective actions for obtaining optimal sleep, including modifications of behavioral and environmental factors, should be one of the major concerns of public health.

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Background Antithrombotic agents, including antiplatelet agents, anticoagulants and thrombolysis agents, have been widely used in the management of immunoglobulin A (IgA) nephropathy in Chinese and Japanese populations. To systematically evaluate the effects of antithrombotic agents for IgA nephropathy.
Methods Data sources consisted of MEDLINE, EMBASE, the Cochrane Library, Chinese Biomedical Literature Database (CBM), Chinese Science and Technology Periodicals Databases (CNKI) and Japana Centra Revuo Medicina (http://www.jamas.gr.jp) up to April 5, 2011. The quality of the studies was evaluated from the intention to treat analysis and allocation concealment, as well as by the Jadad method. Meta-analyses were performed on the outcomes of proteinuria and renal function.
Results Six articles met the predetermined inclusion criteria. Antithrombotic agents showed statistically significant effects on proteinuria (p<0.0001) but not on the protection of renal function (p=0.07). The pooled risk ratio for proteinuria was 0.53, [95% confidence intervals (CI): 0.41-0.68; I²=0%] and for renal function it was 0.42 (95% CI 0.17-1.06; I²=72%). Subgroup analysis showed that dipyridamole was beneficial for proteinuria (p=0.0003) but had no significant effects on protecting renal function. Urokinase had statistically significant effects both on the reduction of proteinuria (p=0.0005) and protecting renal function (p<0.00001) when compared with the control group.
Conclusion Antithrombotic agents had statistically significant effects on the reduction of proteinuria but not on the protection of renal function in patients with IgAN. Urokinase had statistically significant effects both on the reduction of proteinuria and on protecting renal function. Urokinase was shown to be a promising medication and should be investigated further.

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Objective Although rare, renal amyloidosis is an important diagnosis that bares a significant morbidity and mortality. The purpose of this study was to present current single center experience in the past 28 years.
Methods A total of 6151 kidney biopsies were performed in our hospital from Jan. 1983 to Dec. 2010; 5844 were native kidney biopsies. Cases with a diagnosis of renal amyloidosis were identified through a search of our data bank and the clinical data were retrieved from medical charts. The patients were further classified as AL type and non-AL type. The trend of incidence was analyzed and the clinical features were compared. Risk factors that predict patient mortality were discovered by logistic regression analysis.
Results Forty out of 5844 native kidney biopsies (0.68%) were identified as renal amyloidosis. Eighteen (45%) were of AL type. The mean age at diagnosis was 62.6 ± 13.4 years. Male was the predominant gender that was involved. Clinically, most (80%) have nephrotic range proteinuria (mean 24 hours urine protein: 6.9 ± 4.7 g). With a mean follow-up duration of 1155 day, the 1-year and 5-year patient survival were 42.9% and 17.9%, respectively. eGFR at biopsy was the sole predictive factor for patient survival.
Conclusion Senile patients with nephrotic syndrome should elicit the suspicion of renal amyloidosis. The incidence appeared to be increasing and the prognosis poor.

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Background Patients who have been on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years are known to have a risk of developing encapsulating peritoneal sclerosis (EPS). However, the prognosis of patients on CAPD for over 10 years remains unclear.
Methods To better understand the efficacy of a variety of treatments for EPS, we retrospectively reviewed 25 patients who started CAPD at Toranomon Hospital from 1981 to 1997 and continued it for longer than 10 years.
Results The CAPD catheter was removed without peritoneal lavage in the initial 3 patients and they developed massive ascites. They all died of infection without resolution of the ascites. Accordingly, in the remaining 13 patients who did not undergo kidney transplantation, peritoneal lavage therapy was performed for 12 months before removing the CAPD catheter. As a result, 4 patients did not develop EPS. However, 9 patients had EPS with ascites, among whom 4 died of EPS-related diseases and 5 are alive. Five patients underwent cadaveric donor kidney transplantation. At the time of surgery, the CAPD catheter was removed without peritoneal lavage; 1 patient suffered from massive ascites immediately, although this subsided within 3 months after kidney transplantation, and 4 patients remain free from EPS-related symptoms and are doing well.
Conclusion Kidney transplantation may be an option for preventing EPS. This study showed that improvement of the uremic state as well as treatment with immunosuppressants including corticosteroids may contribute to preventing EPS.

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Objective The determination of mediastinal lymphadenopathy is important in the management of extrapulmonary malignancy. The purpose of this study was to determine the diagnostic performance of EBUS-TBNA in the diagnosis of mediastinal and hilar lymphadenopathy in patients with proven or suspicious extrapulmonary malignancy.
Patients and Methods Retrospective analysis was performed in 57 patients (81 lesions) with proven (n=51) or suspicious (n=6) extrapulmonary malignancies who underwent EBUS-TBNA between May 2009 and January 2011.
Results There were 37 male and 20 female patients, with a median age of 64 years. Thirty-five (61.4%) patients were confirmed as malignancy (34 extrapulmonary malignancy and 1 primary lung cancer) and 22 (38.6%) patients were confirmed as benign. EBUS-TBNA identified malignancy in 30 patients. One patient who was diagnosed as primary lung cancer was excluded from diagnostic performance analysis. Overall cancer prevalence was 61% in 56 study patients. The diagnostic sensitivity, accuracy, and negative predictive value of EBUS-TBNA per patient were 88%, 93%, and 85%. The diagnostic sensitivity, accuracy, and negative predictive value of PET/CT scan per patient were 81%, 82%, and 71%, respectively. There were no serious complications related to EBUS-TBNA.
Conclusion Since mediastinal and hilar lymphadenopathy do not always result from metastases in patients with extrapulmonary malignancy, histopathologic confirmation is mandatory. EBUS-TBNA is a sensitive modality and can be considered as the initial test for the histopathological diagnosis of mediastinal and hilar lymphadenopathy in patients with extrapulmonary malignancy.

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Background and Objective The endurance time has been reported to be the most sensitive measure of improved exercise capacity in response to a variety of interventions for COPD. The aim of the present study was to determine whether the improvements in quadriceps force and measures obtained from a symptom-limited maximal test contributed to the improvements in endurance time following pulmonary rehabilitation.
Methods Fifty-seven consecutive COPD subjects completed a 10-week pulmonary rehabilitation program. The subjects completed a symptom-limited incremental cycle ergometry test and a constant work rate test before and after pulmonary rehabilitation. Peripheral and respiratory muscle strength was also measured. The relationships between the change in endurance time and the changes obtained from the incremental test and muscle strength test were investigated.
Results The endurance time showed the greatest improvement among the exercise capacity indices. The changes in endurance time were significantly correlated to changes in quadriceps force, peak work rate, anaerobic threshold and work efficiency on the incremental load test. In the multiple stepwise regression analysis, changes in quadriceps force and work efficiency measured on the maximal exercise test were selected.
Conclusion These findings suggest that the improvements in endurance time after pulmonary rehabilitation may be explained by increased quadriceps force and improvements in peak work rate and work efficiency.

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Objective To determine the nutritional factors that influence disease spread in patients with pulmonary Mycobacterium avium complex (MAC) infection.
Methods A prospective observational study.
Patients Patients with pulmonary MAC infection were enrolled in this study. Chest computed tomography (CT), abdominal CT, and physical, clinical, and nutritional laboratory data were collected after obtaining informed consent.
Results Seventy-eight patients (16 males and 62 females) were consecutively enrolled. While the mean body mass index (BMI) was low (19.6 ± 2.7 kg/m²), the mean serum albumin concentration was within normal range (4.2 ± 0.2 g/dL). We evaluated the number of affected lung segments to define the degree of disease spread, and examined the relationships between various parameters and disease spread. Multivariate analysis identified the duration of the disease (+1.6 segment/100 months, p=0.03), BMI (-0.5 segment/BMI, p=0.003), and white blood cell count (+0.7 segment/1,000 WBC, p=0.03) as factors contributing to disease spread.
Conclusion BMI is an excellent marker for nutritional assessment and for predicting disease spread in patients with pulmonary MAC infection.

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Background Maximal expiratory flows (MEFs) depend on the elastic recoil pressure in the alveoli, airway resistance and bronchial collapsibility. MEFs at lower levels of vital capacity [MEFs at x% FVC (MEF_x)] would indicate the patency of peripheral airways. In Japan, a ratio of MEF₅₀ to MEF₂₅ (MEF₅₀/MEF₂₅) greater than 4.0 is used as an index of injury to the small airways in subjects without airflow limitation. However, to date there have been no epidemiological investigations relating to this index. The aim of this study was to evaluate the impact of cigarette smoking on MEFs in a general population, and to assess the validity of using this index to evaluate injury to the small airways.
Methods Subjects aged 40 years or older (n=2,917), who had participated in a community-based annual health-check in Takahata, Japan, were enrolled in the study. MEF₇₅, MEF₅₀ and MEF₂₅ were measured in these subjects.
Results In smokers, as compared with never-smokers, the percentage predicted MEFs (%MEFs) decreased according to the aging of the population, except in the case of %MEF₂₅ in females. In males, but not in females, %MEFs decreased significantly with an increase in cigarette consumption. In both genders, MEF₅₀/MEF₂₅ was slightly, but significantly, elevated with aging of the population. In addition, 36.5% of subjects who participated in this health-check had MEF₅₀/MEF₂₅ values greater than 4.0. No difference in MEF₅₀/MEF₂₅ was observed between smokers and never-smokers.
Conclusion Cigarette smoking enhanced the age-related decline in MEFs. Since many healthy subjects aged 40 years or older have MEF₅₀/MEF₂₅ values greater than 4.0, the use of this criterion may over-estimate the presence of small airway disease.

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Objective While the somatic mutation of Janus Kinase 2 (JAK2) and the thrombopoietin receptor (c-MPL) gene are thought to affect the pathogenesis of bcr/abl negative chronic myeloproliferative neoplasm (MPN), the relationship between the mutation and the clinical features remain obscure.
Methods The mutation status of these genes in granulocytes, platelets, T-cells, and erythroid colonies (BFU-E) was obtained from 115 MPN patients, and then the clinical features of the MPN subtypes were compared.
Results The JAK2-V617F mutation was observed in three lineages of granulocytes, platelets, and BFU-E in almost all polycythemia vera (PV) and primary myelofibrosis (PMF) patients. In contrast, 68% of essential thrombocythemia (ET) patients have the JAK2-V617F mutation in at least one of the lineages, of which 70% of these patients have the JAK2-V617F mutation in three lineages; the remaining ET patients with the JAK2-V617F mutation only exhibited the mutation in one or two lineages. Further, the ET patients that exhibited the JAK2-V617F mutation in three lineages had higher WBC and granulocyte counts as compared to the ET patients that did not have the JAK2-V617F mutation or only had the mutation in one or two lineages. Concerning the MPL gene, two ET patients had the MPL-W515L gene mutation in their platelets, although the lineage of the JAK2-V617F mutation involved differed from case to case.
Conclusion The progenitor cells that are involved with the JAK2-V617F mutation in MPNs are different in each subtype and this difference may also affect the clinical features of MPNs.

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Background The relationship between osteonecrosis of the femoral head (OFH) and liver cirrhosis is controversial. The aim of this study was to determine whether liver cirrhosis is associated with the occurrence of OFH.
Methods We used the National Health Insurance Database, derived from the Taiwan National Health Insurance program. The study cohort comprised 40,769 adult patients with liver cirrhosis. The comparison cohort consisted of 40,769 randomly selected age- and sex-matched subjects.
Results During the 3-year follow-up period, there were 321 (0.8%) cirrhotic patients with OFH, and 126 (0.3%) non-cirrhotic patients with OFH (p<0.001). Cox's regression analysis, adjusted by the patients' age, sex, and other confounding factors, showed that the cirrhotic patients had a higher risk for occurrence of OFH than non-cirrhotic patients during the 3-year period (hazard ratio=2.38, p<0.001). In this 3-year study, the incidence density of cirrhotic patients hospitalized for OFH was 3 episodes/1,000 person-year.
Conclusion We conclude that cirrhotic patients have a higher risk for occurrence of OFH than non-cirrhotic patients.

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Mucosal prolapse syndrome (MPS) has been recognized as a chronic benign inflammatory disorder, characterized mainly by rectal mucosal prolapse. Disorders representing this condition include solitary rectal ulcer syndrome (SRUS), rectal prolapse, proctitis cystica profunda, and inflammatory cap polyps. The gross appearance of rectal MPS can be occasionally misinterpreted as rectal cancer. In contrast, there have been a few reports of colorectal cancer originating from prolapsed mucosa. Herein, we report a case of MPS associated with two independent rectal cancers extending into the submucosal layer. We speculate that long-standing MPS may increase the risk of malignant transformation.

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Crohn's disease (CD) is not rare in recent years, but it is sometimes difficult to make a definite diagnosis particularly if it is in the small intestine. We report a patient with fever for 8 months whose disease was mistaken to be Adult onset Still's disease. The patient was diagnosed small intestine Crohn's disease at last by pathology. We want to emphasize that doctors should not forget small intestine Crohn's disease when encountering an unidentified feverish patient, they should not diagnose a feverish patient of Adult onset Still's disease at once. It is important to note that corticosteroids can conceal many diseases and they should not be considered lightly even if the patient is diagnosed with Adult onset Still's disease.

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Mesenteric neurilemmoma is extremely rare. We present a case of a 45-year-old man with mesenteric neurilemmoma, with CT, MRI and angiographic findings. The patient was healthy and had had no symptoms previously. CT and MRI images revealed a 2.2-cm well-defined, soft-tissue mass adjacent to the posterior border of the left lobe of the liver. The tumor mass displayed a heterogenous low signal on T2-weighted image and peripheral enhancement after gadolinium administration. Angiography showed a hypervascular mass beneath the tail of pancreas, which was supplied by small branches of middle splenic artery. Histopathology revealed a mesentery neurilemmoma composed of spindle tumor cells.

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A 69-year-old female complained of persistent abdominal pain, and annular ulcers and ulcer scars were detected endoscopically in the cecum. Pathological findings included caseous granulomas with some Langhans giant cells, and Ziehl-Neelsen staining was negative. Mycobacterium gordonae (M. gordonae) was identified by the DNA-DNA hybridization method and culture (Ogawa medium) of biopsy samples from ulcerous cecal lesions. After 6 months of antibiotic therapy, ulcerous cecal lesions were healed, and no acid-fast bacteria were detected by culture of biopsy samples from scar tissue. We believe this is the first report of M. gordonae infection in the alimentary tract.

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We report a case of recurrent variant angina pectoris which occurred even while receiving antispastic treatment. Coronary angiography revealed no obvious lesion. Behçet's syndrome was diagnosed based on recurrent oral aphthous and genital ulcer as well as skin manifestation. After treatment with immunosuppressant, neither angina nor oral ulcer relapsed. We strongly believe that the variant angina is due to coronary vasospasm induced by Behçet's syndrome in this patient.

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This case report describes incessant monomorphic ventricular tachycardia (VT), not Torsade de Pointes, induced by intravenous amiodarone in a 48-year-old woman with dilated cardiomyopathy. VT was reproducibly triggered by short coupled premature ventricular complex (PVC) with different morphology from VT. After amiodarone infusion, the coupling interval of initiating PVC was prolonged, and moreover, the morphology of initiating PVC became the same as that of VT. Though amiodarone has become the first line drug to treat ventricular tachyarrhythmias in patients with cardiac dysfunction, it is important to be aware of its proarrhythmic effect, which may lead to an electrical storm of monomorphic VT.

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Isolated left ventricular noncompaction (IVNC) is a rare congenital anomaly. The clinical manifestations include congestive heart failure, systemic thromboemboli, arrhythmias and sudden death. We report a case of IVNC in a male patient who presented with atrial fibrillation with complete heart block.

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The association of variant angina (VA) and myocardial bridges is a rare finding. We describe a case of VA with recurrent coronary spasm triggered by different stimuli at the site of a myocardial bridge. The interplay of endothelial dysfunction, coronary vasoconstriction and myocardial bridging was detected by intracoronary acetylcholine test and IVUS. We speculate that mechanical stimulation at the bridge site caused endothelial dysfunction and enhanced local susceptibility to vasoconstrictor stimuli. Variant angina should always be suspected in cases of ST-elevation acute coronary syndrome without any significant angiographic coronary stenosis.

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Carbon monoxide intoxication is one of the most common types of poisoning in the world. Cardiac manifestations after exposure to carbon monoxide including myocardial ischemia, heart failure and arrhythmias have been reported. A 17-year-old woman was admitted to the emergency service with the complaints of palpitation, headache and nausea. Electrocardiogram revealed supraventricular tachycardia. The arterial blood gas analysis was normal. Her carboxyhemoglobin level was 19% and oxygen treatment was started promptly. Echocardiographic examination demonstrated normal cardiac function. To the best of our knowledge, this case report is the first carbon monoxide intoxication case in the literature presenting with supraventricular tachycardia attack.

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A 62-year-old man was admitted to our hospital because of melena. On admission physical examination revealed that he had typical features of Noonan syndrome (NS). Investigation via upper endoscopy with the single balloon demonstrated oozing from the small intestine. Bleeding sometimes occurs in patients with NS. We speculated that coagulation defects or vascular malformations might have been present at the first visit in this case. However, coagulation function was normal. By upper endoscopy with the single balloon we clearly revealed the angioectasia in the small intestine. This case documents the first association among NS, aortic regurgitation and angioectasia in the small intestine.

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We encountered a case of plasmablastic extramedullary plasmacytoma with multiple myeloma. Histological findings revealed that the extramedullary plasmacytoma of this patient was of the plasmablastic type, which was positive for λ-stain and EBV-encoded RNA. In contrast, bone marrow aspiration demonstrated a common-type multiple myeloma, which was positive for λ-stain and negative for EBV-encoded RNA. This was a rare case of plasmablastic extramedullary plasmacytoma associated with Epstein-Barr virus arising in an immunocompetent patient with multiple myeloma.

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A 66-year-old man with Cushing's syndrome due to adrenocorticotropin-independent bilateral macronodular adrenocortical hyperplasia (AIMAH) was treated for 7 years with trilostane, a 3β-hydroxysteroid dehydrogenase inhibitor. Administration of trilostane reduced the serum cortisol level to around the upper limit of normal for 7 years, and symptoms of excessive glucocorticoid production (such as moon face and obesity) were gradually improved. On the other hand, the size of both adrenal glands gradually increased despite treatment with trilostane. Though trilostane therapy could not prevent adrenal growth, it did suppress cortisol secretion over the long term, so it might be a reasonable option for AIMAH in addition to adrenalectomy.

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An 82-year-old Japanese man had consciousness disturbance due to severe hypothyroidism triggered by percutaneous absorption of iodine from an iodine-containing ointment used in diabetic gangrene treatment. Laboratory data revealed extremely high urinary iodine concentrations, and chronic thyroiditis-induced hypothyroidism. Excess iodine intake can also cause hypothyroidism. It was unlikely that iodine intoxication or Hashimoto's encephalopathy had caused the consciousness disturbance. The patient regained consciousness after discontinuing the use of the ointment and commencing thyroid hormone therapy. We conclude that consciousness disturbance resulted from severe hypothyroidism caused by chronic thyroiditis and excess iodine absorption.

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Extracorporeal shock-wave lithotripsy (ESWL) is an effective and relatively non-invasive treatment modality for ureteral or renal calculi. Although it has been accepted as a safe procedure, minor and major complications have been reported after ESWL. Spontaneous renal artery dissection (SRAD) is a rare and usually misdiagnosed condition because of non-specific presentation of the patients. Depending on the severity of the extent of the dissection non-operative or surgical treatment modalities could be performed. We represent a patient with complaints of bilateral flank pain, hematuria and hypertensive urgency who was diagnosed as having bilateral SRAD possibly secondary to ESWL and chronic hypertension.

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A 57-year-old woman was referred to our hospital for further examination of a tracheal stenosis shown on computed tomography findings. Bronchoscopy revealed multiple protruding tumors in the lumen of the trachea. Cytological findings of the cell block material from pleural effusion indicated that the T-cell lymphoma was composed of pleomorphic lymphoid cells. Serum human T-cell leukemia virus type1 antibody was positive and supported the clinical diagnosis of ATLL. Systemic chemotherapy induced the remarkable improvement of the lesions, the infiltrative lung shadow and the soft tissue neoplasm. We report a rare case of adult T cell leukemia/lymphoma (ATLL) with endobronchial involvement.

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Gaucher's disease is an autosomal recessive inherited disease characterized by oraganomegaly, cytopenia and bone destruction. Clotting disorders and platelet dysfunctions are described. We report the case of a 22-year-old man who presented subacute groin pain due to spontaneous iliopsoas hematoma. Laboratory investigations found moderate thrombocytopenia, normal coagulation factor activities and unspecific platelet function test disturbances. His spleen was moderately enlarged and no significant bone lesions were found. Iliopsoas hematoma is a rare complication in Gaucher's disease and should be included in the differential diagnosis of pain localized to the groin-hip area, which could rather evoke hip osteonecrosis in this context.

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The activating mutation of JAK2, V617F, has been found as a frequent mutation in myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocytosis (ET), and primary myelofibrosis (PMF). This mutation is observed not only in MPNs, but also in chronic myelomonocytic leukemia, myelodysplastic syndrome and acute myeloid leukemia (AML). We report a case of myeloid sarcoma and myelofibrosis, followed by secondary AML, with detection of homozygous JAK2 V617F mutation. This report describes the first case of myeloid sarcoma with JAK2 V617F mutation and implication of its progression to AML.

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Immunoglobulin D (IgD) myeloma is a rare subtype and it is widely accepted as an aggressive disease. Here, we report a 66-year-old woman with IgD myeloma who had anemia, lumbago, multiple osteolytic lesions and hypercalcemia. The patient refused a blood transfusion because of her beliefs, so we administered bortezomib and dexamethasone (BD) after high-dose dexamethasone therapy. Marked improvement of anemia and elevated serum alkaline phosphatase levels was recognized. After 5 cycles of BD therapy, the patient achieved a stringent complete response according to International Myeloma Working Group Response Criteria. BD therapy might be a feasible and useful treatment option for IgD myeloma.

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A 50-year-old man presented with an ileocecal tumor and a large amount of ascites. Lymphoma cells obtained from the ascitic fluid were CD10⁺, CD20⁺, CD38⁺, HLA-DR⁺, BCL6^-, MUM1/IRF4⁺, BCL2⁺, and immunoglobulin μ/γ⁺. The karyotype determined by G-banding and spectral karyotyping was 46, XY, der(3)t(1;3)(q12;p12), -4, +7, t(8;14)(q24;q32), t(12;14)(q24;q32), der(17)t(4;17)(q21;p11). Fluorescence in situ hybridization disclosed that 93% of interphase cells were positive for the c-MYC and immunoglobulin heavy chain gene fusion. The patient was treated with intensive chemo-immunotherapy, resulting in a complete response. The t(8;14)-t(12;14) double-hit may have generated molecular abnormalities analogous to those of a previously cloned three-way translocation t(8;12;14).

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We report an adult case of late-onset riboflavin-responsive multiple acyl-CoA dehydrogenase deficiency (MADD) characterized by episodic recurrent rhabdomyolysis and acute renal failure after the age of 46. Muscle biopsy revealed lipid storage myopathy and the finding of serum acylcarnitine and urine organic acid analyses were consistent with MADD. A compound heterozygous mutation was identified in the electron-transferring-flavoprotein dehydrogenase (ETFDH) gene, including a novel missense mutation, which confirmed the diagnosis of MADD. After administration of riboflavin and L-carnitine, the muscle weakness and fatigability gradually improved. Acylcarnitine and urine organic acid were also normalized after supplementation. Thus, MADD should be included in one of the differential diagnoses for adult recurrent rhabdomyolysis. Gene analysis is useful to confirm the diagnosis, and early diagnosis is important because riboflavin treatment has been effective in a significant number of patients with MADD.

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Acute myocardial infarction (AMI) is one of the most severe manifestations in patients with systemic lupus erythematosus (SLE). Ischemic colitis, mainly caused by intestinal vasculitis, is also one of the most serious, but uncommon, complications in SLE patients. "SLE vasculitis" simultaneously involving cardiac and gastrointestinal vessels has yet to be reported. This is the first report of SLE accompanying AMI, ischemic colitis and perforation of the digestive tract possibly due to SLE vasculitis, which was dramatically improved by treatment with high-dose glucocorticoid.

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A 67-year-old woman presented with melena and general weakness. Upper gastrointestinal (GI) endoscopy revealed multiple ulcers and projectile bleeding in the stomach. She also complained of a 10-day history of a fever and was diagnosed with scrub typhus based on a positive result of the eschar polymerase chain reaction (PCR) testing. She fully recovered with endoscopic hemostasis, and administration of minocycline and omeprazole. In a patient with GI manifestations, scrub typhus, a condition with pathologically systemic vasculitis, should be considered in the possible background in endemic areas. The eschar PCR testing is a rapid and useful diagnostic tool to identify a specific strain.

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